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Health & Medicine

What You Need To Know About Telehealth Fraud

— April 30, 2019

Telehealth fraud is one of the downsides to an otherwise great idea. Telemedicine brings care to patients who may not be able to access the healthcare system in the traditional manner.

Telehealth fraud is an unfortunate scam in the medical industry that is rapidly growing. More and more individuals are tricked into falling for it, despite a recent widespread awareness. Telemedicine refers to the practice of treating patients via technology. The patient no longer has to see the doctor personally, as you can complete your consultations via video calling, for example. However, for others, this excellent consultation idea of telehealth has become a scheme, creating the problem of telehealth false claims fraud.

This article will give you everything that you need to know about this fraudulent scam.

Telehealth started as a positive endeavor of reaching out to rural areas.

If you live in the city, reaching the best healthcare and medical providers shouldn’t be a problem. However, if you live in rural areas, the situation is different. Sometimes, it may be difficult to travel to a medical provider in case of an emergency, or for a check-up. This situation can even be made more difficult if you have physical impairments.

 Telehealth was an excellent project to provide medical access to places where it was limited, and to allow individuals to save money as well, as they no longer have to travel far for consultations.

Man typing on laptop computer; image by Glenn Carstens-Peters, via
Man typing on laptop computer; image by Glenn Carstens-Peters, via

Telemedicine is not just limited to screen-to-screen consultation.

The common misconception about telemedicine is that it is only limited to screen consultations. No, this is false. The reason why telemedicine has been so susceptible to fraudulent transactions and abuse by others is because its scope is so broad, that it is so easy to create loopholes. 

Other examples of services that are related to telemedicine include:

  • A cardiologist checking on their patients, reviewing charts, checking live results, beats, and rhythms.
  • A radiologist interpreting graphs and messages from a different clinic, which can even be done live.

Telemedicine reimbursements are subject to certain conditions.

Although telemedicine is widely practiced in almost all states today, there are still many states that have their own laws or regulations regarding it. Hence, it is best for you to double check with your private Medicare or Medicaid state provisions, to double check on whether this state insurance can reimburse you for your telemedicine transactions.

For example, as a patient, for you to qualify for reimbursement from Medicare for your Telehealth consultations, you must satisfy the following conditions:

  • As the patient, you must be at an originating site or a place that is legally approved for Telehealth.
  • You must consult with a physician who is licensed to practice Telehealth under the state law of the distant site location of your practitioner.
  • Your communication lines with your distant physician should be either through audio or video, that is also applicable for real-time or live communication.
  • The CPT code of the service provided during your telemedicine consultation should be included in the list of current services offered by Medicare for the year.
  • Your medical examination should be solely controlled by the physician that you are consulting with, and not by any other doctor from a non-distant site.

Telehealth fraud began through the improper coding of services.

As Telehealth expanded, so did its exposure to fraud and abuse. Because these vulnerabilities are not adequately addressed, fraud started to increase and became more rampant. The most significant area in which fraudulent schemes began to prosper is through improper billing.

Improper billing started proliferating by the following practices:

  • Claims from patients who were listed as coming from rural areas, but came from non-rural areas.
  • Claims from non-eligible or non-listed institutional providers.
  • Claims from unacceptable means of communication.
  • Claims from services that are not covered by this service.
  • Claims from prescriptions that aren’t legally made, or that are tampered.

Telehealth transactions also became vulnerable to kickback measures.

The term kickback refers to the process of giving anything, such as money and other favors, in exchange for the approval of, or the referral of one’s business to Telehealth transactions. Typically, the government will provide a bidding system to these private companies, and whoever wins or presents the best bid, becomes approved to be the provider for this Telehealth system.

For example, the following companies:

  • Providers of computers
  • Providers of accounting software and recording systems
  • Providers of insurance that will reimburse Telehealth transactions, such as Medicare

The Law, under the Anti-Kickback Statute, strictly prohibits the kickback system. However, despite the presence of this law, this practice is still highly apparent, especially in Telehealth fraud. Instead of going through the legal processes and systems, bribes have been offered and widely accepted.

Fraudulent telehealth transactions have signs that can help you be aware of the same.

The most common victims who fall prey to the telehealth scheme are the doctors. Often, the doctors’ names and accounts are used to collect proceeds from insurance companies for patients that the clinic hasn’t even met at all. The negative thing about this is that if you get caught, although you are as innocent as the doctor who got tricked, you can fall prey to being implicated as part of the scam.

To avoid it, here are some of the telltale signs that you are being scammed:

  • The difficulty of communication with the management of the clinic
  • Problem of contact with the patients
  • Very few numbers of doctors in the clinic, despite an unusually high volume of patients
  • The fast patient turnover rate in a day
  • Patients who finish their consultations online or on the phone are unusually fast
  • Speedy return or salaries in thousands of dollars a month, at a rate sooner than any reasonable doctor would earn

Telehealth fraud can be avoided through consulting a lawyer for each of your transactions.

Most of the victims of the Telehealth frauds are newbie doctors and even newbie contractors and providers of medical-related services. Whenever you are called to apply in a company and have unusually high returns or salaries, refrain from immediately signing a contract of undertaking or employment without first seeking the advice of a lawyer. If any of the terms of the deal seem dubious to you, ask a lawyer to interpret them as well.

Remember that the act of affixing your signature in a contract agreement means that you fully understand and agree to all the terms provided in it. Once the document is signed, it is difficult for you to prove that you were unaware of a particular fact, once you fall prey to a Telehealth fraud, or any other scam, for that matter. Seeking the advice of a lawyer first can help outline and lay everything out to you in the clearest and most concise manner possible.

Telehealth fraud can be avoided by the simplest act of care and prudence on your part.

No, you do not need to be an expert in technology or anything technical for you to protect yourself from telemedicine fraud. As doctors are the most vulnerable prey to this scheme, the best way for you to protect yourself is to make your list of every prescription that you’ve approved, and even those that you denied. Just think of it like you are a businessman who always makes a list for inventory at the end of every day.

With advancements in technological software, you cannot be assured that the prescription that you denied through your telemedical conference is rejected on the other hand. Also, you cannot double check if one prescription that you made from your end has multiplied to ten on the other end, to count for abuse or nine ghost prescription transactions. The best way for you to combat this problem is to make your own inventory as well, so that in the event that you might get questioned for any doubt or difficulty, you have a little shield of protection for yourself.

Another most pressing reason why you, as the doctor, should keep your inventory of the prescriptions that you prescribed, is so that you can also double check on the amounts. In the telehealth scheme, a company was once indicted for doubling or tripling the value of the medicine prescribed by doctors so that they can keep the remaining claims from the insurance for themselves.

Telemedicine is still very beneficial to the healthcare industry.

If not for the fraudulent schemes that have been surrounding the telemedicine industry, it is an excellent project of the government for the healthcare industry. As telemedicine is still very much around today, this article is not meant to scare you and discourage you from entering it as a physician, or seeking out this service as a patient.

You will still gain so much benefit from telemedicine, especially the ease of service that it offers. This article is only meant to make you aware of the schemes surrounding it so that you are not going to be the next one who will fall into the ill motives of scammers who are taking advantage of the telehealth industry.

Through the advancement of technology, the healthcare system has entered an exciting time. Fresh innovations are making the delivery of healthcare services even better, smoother, faster and more accessible. 

The only downside to it is that the use of technology has also led to its abuse. Therefore, there should be a collective process between the government, the healthcare industry, and the patients as well, to avoid telemedicine fraud, and keep it from destroying the possibilities and advantages that telemedicine could bring to developments in medical treatment.

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